The primary course to mitigate neglected mental health problems of HCWs should be to offer a reduction in their working hours.
The virus SARS-COV-2 appeared first in the final quarter of 2019 allegedly, and it has been the cause of an omnipresent pandemic ever since. Its effects have been felt cross-sectionally across all age groups, professions, nationalities, races, classes, inter alia, but perhaps by some more than others. Healthcare Workers (hereinafter, HCWs) have been at the forefront of a long-drawn battle against the virus and they fall within the class of persons who have arguably been overworked during the past few months. This burden expectedly takes a toll on their physical and mental well-being. Hence, the aim of our analysis is to attempt to analyse this ensuing impact of COVID-19 pandemic on the mental health of HCWs and to suggest policy recommendations to control the virus more efficiently by effectuating an increase in the mental health of medical staff.
MENTAL HEALTH IMPACT ON HEALTHCARE WORKERS (HCWS) DURING THE PANDEMIC
Early tests indicate that HCWs are at an alarmingly higher risk than other individuals during the pandemic, with 58.6% of subjects showing symptoms of psychological disorders. Even before the release of this official data, 43.5% medical personnel self-reported issues of anxiety, insomnia, PTSD and other psychological disorders in a survey. Contrastingly, the reported levels of psychological problems in general populations can be pinned closer to 20% on an average. Therefore, it is no surprise that the empirical statistical data only verifies the obvious.
PRESENT LAW IN INDIA ON MENTAL HEALTH
No legislation in India creates any rights for a multitude of disorders including the likes of anxiety, PTSD and insomnia which have been the major source of discomfort for HCWs during the pandemic. The remedies available under the Mental Healthcare Act, 2017 are only applicable to people who are incapacitated from performing their day-to-day chores and are thereby categorized as individuals with a mental illness. Therefore, HCWs cannot claim any rights under that Act as well.
MEASURES IMPLEMENTED ELSEWHERE (COMPARATIVE INTERNATIONAL JURISPRUDENCE) TO TACKLE THE PROBLEM
However, the impact of the rapidly advancing COVID-19 on HCWs has not gone unnoticed by State authorities in most countries. For instance, in China, intricate psychological assistance plans were devised for all healthcare workers involved in minimising the spread of the virus. Regardless, these were not availed largely, and were in fact rejected stoically by more than most healthcare workers, much to the dismay of the State. However, despite the outright rejection, the workers conceded that they were overworked and the meteoric rise in working hours cannot be compensated with even the best of psychological help. The refusal of HCWs to obtain psychological help should not be misread as denial of a presence of psychological problems.
Considering the evidence adduced, it is suggested, almost counterintuitively, that the primary course to mitigate neglected psychological problems of HCWs should not be to implement a psychological crisis intervention model (PCIM), i.e., offering professional psychological assistance to HCWs, as has been the approach of most States including China and Italy (where the virus has seen vast outbreak comparable to India) but instead to offer a reduction in their working hours. This argument can be corroborated by a positive response shown in the psychological tests of HCWs in China after reduced workload on individual personnel and regular shift changes. This is not to say that professional psychological assistance must not be provided at all, but rather that it must be a secondary or even tertiary means of amelioration for psychological problems developing in HCWs during the pandemic period.
National Mental Health Programme, 1982, Mental Health Act, 1987 and the newer Mental Healthcare Act, 2017 all fail to bring cases of anxiety, depression, insomnia, PTSD, etc. within their ambit which form the majority of psychological problems faced by HCWs during this period. Part of the reason of a lack of legislation on these problems is their perception in Indian society as first-world problems.
Anyhow, considering the shambolic failure of PCIMs set up across various countries to relieve HCWs of psychological stress, it is suggested that reduced work hours, increased availability of PPE equipment and shift changes (discussed in detail later) must be the primal methods to attenuate psychological problems in HCWs. A legislation to that effect could be enforced but considering the exigency of the need of such an Act and the fact that the Parliament is not in session, the President of India is empowered to promulgate an ordinance under Article 123 of the Constitution. Such an ordinance may be promulgated with immediate effect and the Parliament is still at will to qualify it as an Act eventually.
The essential provisions which might be included as a part of the suggested ordinance have been identified as follows (in that order of preference) –
1. WORK HOURS
Presently, the Code on Wages, 2019 allows the government to set the minimum working hours for private and government facilities. Additively, the Code on Wages (Central) Rules, 2020 mandates that the hours spent at workplace must be observed as eight working hours on a normal working day and shall not exceed twelve hours (including rest) on all days. Some complications arise in our case due to the Supreme Court’s ruling in ESI Corporation Medical Officer’s Association v ESI Corporation whereby doctors do not fall within the afore-mentioned definition of workers meaning the provision of twelve hours maximum worktime is inapplicable to them. Therefore, not all HCWs are covered under the definition of ‘workers’ under the said Act.
Studies show that the number of working hours bears an inverse relationship to attentional failures while surveys and ground reports suggest that the HCWs in India are being worked more than even the legally mandated time limits under the Code on Wages (Central) Rules, 2020. Such activities of hospitals constitute gross human rights violations, are unconstitutional and liable to face the wrath of the courts.
Being overworked has eventually led to depressive symptoms in HCWs reportedly. In fact, healthcare is the profession with the highest suicidal rates in the country. Considering the afore-mentioned reasons, the government must reduce the workable hours in a day for HCWs to reduce burn-out which could lead to more efficient results than the present output which should be generally beneficial to cater to the needs of a country of 1.35 bn people.
The government should also ensure proper implementation of these guidelines since the present ones have been flouted beyond redemption if the reports are anything to go by. Another clause which could be introduced as a part of these measures is a regular switch between day and night shifts for different employees.
While the non-availability of Personal Protective Equipment (PPE) in third world countries has been the subject of much debate, even where such apparatus has been available, it could not be worn for a consecutive period of eight or more hours due to bodily discomfort and risk of infections due to extended usage. Since the government rules allow only for a maximum one-hour rest period in a working day, it is unfeasible to expect HCWs to wear PPE for the entirety of their twelve-hour long shifts. The government must consider the inclusion of efficient work-rest cycles.
3. NEEDS-BASED PCIM APPROACH
While we have ignored the necessity of establishing a PCIM programme throughout the course of our discussion in this paper, we advocate for such a need through this argument. The variance in the tasks handled by different HCWs exposes each worker to varying levels of risks and thereby, leads to vast differences in their psychological experiences. Also, the nursing department shows relatively increased levels of stress during the pandemic due to various factors such as having to tend to waves of patients simultaneously, informing families of deaths of patients, being morally guilt pressured into reporting to work due to the nature of their profession, etc. This argument is further substantiated by the data available from a survey of nurses attempting to minimise the impact of COVID-19 in Wuhan, China who reported an increase in the presence of psychological disorders as compared to other HCWs. Female HCWs, especially those who were not in a relationship at the time of the survey, also showed a rise in symptoms of psychological disorders.
It is clear from our discussion above that a multitude of factors such as gender, age, work department and level of risk at work are responsible for determining the probability of psychological disorders present in HCWs dealing with COVID-19 patients. Therefore, the government must regard the psychological impact on HCWs working in high-risk environments, nursing department, gender, age, etc. accordingly to fashion a PCIM programme in India.
The government should provide for reduced working hours and frequent work-rest cycles to increase the efficiency of healthcare workers during the pandemic period. This, in turn, would mean that more work gets done despite the official hours being fewer in number. Offering professional psychological help is no remedy but mere oil to keep an overburdened Indian medical department functioning.